Outbreak

A Maddening Case of the Measles in Orthodox Jewish Brooklyn

More than 50 children in Brooklyn’s Jewish enclave have developed measles this spring—a number far too high for a virus easily prevented with a vaccine.

Oy. Another infectious disease is running through the Orthodox Jewish community in Brooklyn.

More than 50 children have developed measles this spring—the third or fourth measles problem in the community in the last six years, and following closely on the heels of a mumps outbreak in 2009–10 that affected more than 3,000 people. And don't forget the still-ongoing spread from a ritual circumciser to newborn male foreskin of cases of the sometimes fatal herpes simplex.

The spread of each of these infections is fueled by something different. For measles, the cause is quite simple. Kids aren't getting vaccinated. As the New York City Department of Health and Mental Hygiene (DOH) wrote in its June 4 update on the ongoing outbreak, "To date, there have been 48 confirmed cases, including 28 in Borough Park and 20 in Williamsburg ... All cases were in persons who were unvaccinated at the time of exposure, because they were too young to have been vaccinated or because their parents delayed or refused vaccine for their children."

So there you have it: another outbreak fueled by irrational vaccine phobia. Just as phobia about influenza vaccination leads to countless cases of influenza, so too has a long-ago discredited association between the measles vaccine and the risk of autism fueled cases of measles. Indeed, Great Britain is in the teeth of a major measles problem right now, numbering more than 1,000 cases and large enough to warrant an official Wikipedia entry, related to long-ago discredited medical articles associating measles vaccine with autism. Some have suggested that the reluctance of then–prime minister Tony Blair to disclose whether his own young son, Leo, had received the vaccine fueled much national hesitation.

Measles is a potentially severe viral infection that still kills hundreds of thousands of people worldwide. It can cause pneumonia and encephalitis, as well as the telltale rash and “measly” feeling of those who are ill. It also has no treatment—none of the current antivirals have activity against the infection. But the measles vaccine is remarkably effective, as good a shot as we have. In contrast to mumps and influenza vaccines, which have predictable failure rates—meaning vaccinated people can still develop the disease, though at substantially lower rates and with milder symptoms. With measles, to be vaccinated is to be safe.

What the f**k is going on in these areas of Brooklyn?

Given this fact, the only good thing about the current measles outbreak is that the remedy is known and is effective. More and earlier vaccination. Measles vaccine is given as part of the three-infection MMR series along with mumps and rubella (or German measles) typically at age 1 and again in infancy and a third time in adolescence to assure durable immunity. Traditionally, the vaccine, which contains a live, weakened (or attenuated) strain of the virus, has not been given to babies younger than a year old. There are several reasons for this: first, antibody from Mom generally lasts about six months and remains high for much longer in the subset of babies who are breast-fed for more than six months. Second, the live vaccine has been given cautiously to the wee ones because of a concern that their immature immune system might not be able to handle even the weakest of infectious challenges. (More recent studies performed since the CDC recommendations were made have shown this is not the case and the vaccine is safe even in the youngest of babies.) Lastly, there is a concern that, though safe, the young immune system would not make enough antibody to provide protection for the child; in other words, the vaccine would be wasted. Additional work has shown that this too is less of a problem than originally held.

The current outbreak in Brooklyn is forcing a re-working of the recommendations given the epidemiology of the cases seen thus far: to date one in five cases have been seen in those younger than 1 year. Therefore, the revised recommendations are for any child in the orthodox Brooklyn community 6 months or older to receive the first vaccine, with a second shot to be given as usual at 12 months. In addition, non-Orthodox infants who receive medical care in practices that serve predominantly Orthodox kids also should receive MMR at 6 months of age. The additional vaccine should bridge the 6-month-old’s window of susceptibility for the non-breast-fed child and provide enough protection to get the child through.

All of these infectious disease problems—mumps, measles, fatal herpes—occurring in one large population does raise a simple question. And since I am not running for mayor and am thus not in need of the “prized slice of the electoral pie” ascribed to the Orthodox community and because I am Jewish, it is (perhaps) safe for me to ask it: what the f**k is going on in these areas of Brooklyn? How and why does the same group meet time and again with the same calamity of developing quite serious, completely preventable infections?

Surely, high population density may be contributing to the problem—but people are living in crowded quarters throughout New York City. There are lots of young children in many of the families, but this too is echoed elsewhere throughout the city. And there is an ambient amount of distrust, if not mule-headedness, of medicine and government recommendations in this and every other group in New York City.

So why them, why now, and why again and again? Despite endless speculation, it remains totally unclear. But rather than shrug it off and say, oh well, them again, this is a problem that must be examined more closely. After all, these are contagious diseases and represent a substantial public health threat. But once again we find ourselves treading too gingerly along the fault line that separates church and state, where deference and respect to the right of religious freedom and independence has crowded out the responsibility of government to assure public safety.

Yet spiritual safety and medical safety never should be at odds. Despite the political cost to current and future mayors, these complicated, tense, and likely unpleasant discussions must be conducted with the affected Orthodox sects of Brooklyn to control not just the current outbreak but to prevent future problems.

For the health and safety of New York City, this ongoing shanda really must end.